IMPROVING THE HEALTH OF MOTHER AND CHILD: SOLUTIONS FROM INDIA Priya Anant, Prabal Vikram Singh, Sofi Bergkvist, William A. Haseltine & Anita George 2012 PUBLICATION Acknowledgements We, ACCESS Health International, express our sincere gratitude to the John D. and Catherine T. MacArthur Foundation for giving us an opportunity to develop a compendium of models in the field of Maternal and Child Health (MCH). Each of these models has contributed significantly towards developing innovative service delivery models and best practices in the area of MCH in India. In particular, we thank MacArthur Foundation Acting Director Dipa Nag Chowdhury and erstwhile Director Poonam Muttreja for their support, encouragement and time, which made this compendium possible. We appreciate the support and time provided by the leaders and team members of all the organisations that feature in this compendium and sincerely thank them for their support. We are grateful to the Centre for Emerging Market Solutions, Indian School of Business, Hyderabad for supporting us in bringing out this compendium. We thank Minu Markose for transcribing the interviews and Debjani Banerjee, Sreejata Guha, Kutti Krishnan and Mudita Upadhaya for helping us with the first draft of the cases. For editorial support, we thank Debarshi Bhattacharya, Surit Das, Anand Krishna Tatambhotla and SAMA editorial and publishing services. Table of Contents Introduction 01 Society for Education, Action and Research in Community Health (SEARCH) 07 Mamidipudi Venkatarangaiya Foundation (MVF) 22 Ekjut 37 Karuna Trust 48 Action Research and Training for Health (ARTH) 65 School Health Annual Report Programme (SHARP) 85 Janani 101 Child In Need Institute (CINI) 115 Self Employed Women’s Association (SEWA) 129 Society for Education Welfare and Action – Rural (SEWA Rural) 145 Alka Hospital 158 Kurji Holy Family Hospital 169 Mahavir Vaatsalya Aspatal (MVA) 181 Fernandez Hospitals 193 Vaatsalya Hospitals 208 LifeSpring Hospitals 224 Challenges: A summary 226 Observations: An overview 229 Concluding Remarks 244 Introduction In India, many private sector organisations are experimenting and innovating to ensure low-cost maternal and child healthcare services of high quality. There is a growing interest, around the world, in the new practices being developed by these organisations. In this compendium, ACCESS Health International has identified and documented some of these organisations and their successful interventions. This book can serve as a repository of information for healthcare providers, policy makers, researchers and other stakeholders who are interested in new approaches to maternal and child healthcare services. The John D. and Catherine T. MacArthur Foundation have identified maternal and child health care as a priority area and extends support to creative people and effective institutions committed to reducing maternal and child morbidity and mortality. The MacArthur Foundation funded ACCESS Health International and the Centre for Emerging Markets Solutions at the Indian School of Business to develop short case studies that could inspire healthcare providers to adopt good practices. In the book, we have identified and documented 16 providers of maternal and child healthcare services in India and their different approaches. Some of the selected organisations are for-profit, some are non-profit; some provide hospital-based services while others provide community-based services; some work closely with the government and some work independently. What the organisations have in common is interesting approaches to ensure affordability and access to services that other healthcare providers can learn from. The case studies also aim to aid teachers to educate students in medical, public health and business schools on entrepreneurial practices to advance healthcare for mothers and children. This work is also a part of the broader effort by the Center for Health Market Innovations (Result for Development Institute, USA) under which more than 1,000 healthcare providers with interesting practices in emerging markets have so far been identified and documented. Additional information about this initiative is available at www.healthmarketinnovations.org . Overview of the partners ACCESS Health International, a non-profit organisation, aims to improve access to high quality and affordable healthcare services. We identify and document best healthcare practices and health financing mechanisms from around the world and help transfer this knowledge to new markets. We also work with governments and private healthcare providers to design programmes that will help improve access to high quality care. The Centre for Emerging Markets Solutions at the Indian School of Business was established with the conviction that market-based solutions can be devised for many of the developing world’s problems as long as new products and services are developed, proof of concept demonstrated and capital raised to support the initiatives. ACCESS Health International and the Centre for Emerging Markets Solutions came together in 2008 to identify and document good healthcare practices in India. We have visited managers, the staff and the clients of these organisations to understand and document the reasons behind their success. The work covers a broad range of healthcare services – from preventive and primary care to specialist tertiary care services. Method The process of identifying the organisations for the study started with literature reviews and inputs from partners and experts in the maternal and child health space in India. Afterwards, all the selected healthcare providers were visited between June 2010 and February 2011. Structured interviews were combined with long, informal discussions with the entrepreneurs behind these organisations. The process was complemented in most cases by meeting the users of these services and a review of the service delivery data. Inputs from the founders of these organisations helped define the focus of the case studies and identify what others can learn from their work. There are many interesting healthcare organisations in the country; those presented here are some of the most established and appreciated. Many of them have helped influence healthcare policies in India and around the world. 02 The organisations were identified based on three criteria: • improved access to care by providing products and services either in geographies previously lacking healthcare providers or to previously unserved segments of the population; • low-cost of care translated to lower price for care to beneficiaries; and • enhanced quality of care by setting standards and performing research to advance service delivery. The organisations presented in this book are from both urban and rural geographies across India. The case studies showcase how different geographies are associated with different challenges. One example is how healthcare providers in urban areas fight employee attrition and innovate to retain professionals while those in semi-urban or rural areas face a greater problem hiring talent than retaining them. Many of the interesting practices are locale-specific, but the approaches can be applied to other geographies around the world. Overview of the profiled organisations This section provides a brief overview of the organisations documented in this compendium. Society for Education, Action and Research in Community Health (SEARCH) designs its healthcare interventions in collaboration with the community. The organisation has influenced policies and practices globally. Their programme for home-based newborn care has been adopted across the world. The evidence from their research has changed global thinking on newborn survival and the role of community health workers. Mamidipudi Venkatarangaiya Foundation (MVF) educates the community about their rights and encourages democratically elected representatives to pressurise poor performing public health organisations to improve. Ekjut carried out a randomised control trial to demonstrate how participatory learning and action cycle with women’s groups can improve maternal and infant health outcomes. Karuna Trust has engaged with governments to manage remote and non-functional primary health care and referral centres in a state. They demonstrate opportunities for the government to work with the private 03 sector to advance access to high quality healthcare services. They also support the government and private organisations to establish public- private partnerships for improved primary healthcare services across India. Action Research and Training for Health (ARTH) demonstrates how nurses can be trained to independently manage deliveries with good health outcomes. The organisation invests in research to identify harmful practices that lead to poor maternal and infant health outcomes in the villages. They then develop effective communication tools for healthcare workers to reach out to the population and mitigate high-risk behaviours. ARTH has set up systems to help their staff provide timely care during home based deliveries even in hard to reach locales. The Government of Rajasthan has requested ARTH to design manuals and protocols for improving the quality of maternal and child health services in the public sector. This engagement has helped the organisation take its innovative practices to improve maternal and child health beyond the region of their direct engagement. School Health Annual Report Programme (SHARP) demonstrates the need and relevance of